Thyroid examination

Physical Examination

General Survey:

• • Details:

  • Facies: Thyrotoxic facies, Myxoedema facies

  • Neck gland: Thyroid gland is enlarged. Described under local examination

  • Pulse: /min, whether collapsing, rhythm regular described in details in examination for toxic sign

Local Examination- Examination of the Thyroid region

(a) Inspection:

• Ask the patient to swallow and confirm whether the swelling moves up and down with deglutition

• Ask the patient to open the mouth and then put out his tongue. If the swelling moves up it is likely to be attached to the tongue and is likely to be a thyroglossal cyst.

• Position and extent of the swelling- Swelling situated in the front and sides of the neck in the thyroid region- extending laterally upto the sternocleidoastoid, below upto the suprasternal notch and above upto the thyroid cartilage. If both lobes of the thyroid gland are enlarged, describe the extent of each lobe upward, downward and laterally. Both lobes of the thyroid gland is enlarged and extends above upto the thyroid cartilage, below upto the clavicle and laterally upto the posterior border of sternocleidomastoid.

• Describe the extent of the isthmus in the midline- upper and lower extent. The isthmus of the thyroid gland is also enlarged and extends below upto the suprasternal notch and above extends 3cm above the suprasternal notch.

• Shape- (if thyroid gland is enlarged as a whole it may be described as a butterfly shaped swelling. Otherwise describe the shape as it is seen)

• Size- If both lobes and isthmus are enlarged- (Describe vertical and horizontal dimension of each lobe and vertical and transverse dimension of the isthmus separately)

• Surface- smooth/ irregular/ nodular

• Margin-

• Skin over the swelling- Scar/ pigmentation/ venous prominence

• any pulsation

• comment whether lower border can be seen as such or on swallowing

• any venous prominence over neck or chest wall

(b) Palpation:

• Temperature over the swelling

• Tenderness

• Movement of the swelling with deglutition

• Position and extent of the swelling

• Shape

• Size

• Measurement of circumference of the neck at most prominent part of the swelling.....cm

• Surface, margin

• Consistency- (hard, firm, soft, cystic, variegated)

• any pulsation

• any thrill

• any skin fixity

• Mobility- mobility from side to side and up and down.

• Relation of the swelling with sternocleidomastoid muscle.

• Note the positions of trachea & larynx.

  • Any shifting to either side by the swelling.

• Test for tracheal compression- Kocher's test

  • the swelling is pressed slightly on either side of trachea. If trachea is already compressed or if there is tracheomalacia, patient will have stridor.

  • Kocher's test negative (no stridor)

  • Kocher's test positive (stridor on compression of both lobes).

• Palpate the carotid pulsation.

  • Carotid pulsation may be felt at normal site (at the anterior border of sternocleidomastoid at the level of the upper border of thyroid cartilage).

  • Carotid pulse is not palpable on the side of the swelling (Berry's sign positive).

  • Carotid pulse is palpable but is displaced laterally.

  • In a locally advanced thyroid carcinoma sympathetic trunk may be involved. Look for signs of sympathetic trunk palsy (Horner's syndrome)

    • Enophthalmos

    • Pseudoptosis (slight drooping of upper eyelid).

    • Anhidrosis

    • Miosis

    • Loss of ciliosoinal reflex

(c) Percussion: (Percussion over manubrium sterni)

• • Superior mediastinum is normally resonant. If there is retrosternal prolongation of goitre the area may be dull. Percussion of the neck is not helpful.

(d) Auscultation:

• • Any bruit audible or not.

  • In thyrotoxicosis the bruit is audible near the upper pole of the thyroid lobes.

Examination of cervical lymph nodes

• • • Examine of all the cervical lymph node groups: If lymph nodes are palpable, then describe which group of lymph nodes are palpable.

    • No.,site, surface, margin, consistency and mobility.

    • Write details about lymph node enlargement.

Examination for toxic signs:

• • pulse rate, rhythm, volume, any special character- collapsing or not

  • tremors in hands and tongue.

  • thrill and bruit over the thyroid gland usually present at upper pole.

  • Eye signs-

    • Exophthalmos: forward bulging of the eyeball

    • Dalrymple's sign (Lid retraction): Visibility of upper sclera due to spasm of upper eyelid. if present- the sign is positive.

    • Von Graefe's sign(Lid lag): when the upper eyelid can not keep pace with the movement of the eyeball and the upper eyelid lags, then the lid lag is present. The sign is positive.

    • Joffroy's sign: Loss of wrinkling of forehead on looking up- the sign is positive.

    • Moebius's sign: If there is failure of convergence on accomodation at a near object from a distant object, the sign is said to be positive.

    • Stellwag's sign: Infrequent blinking- a stare look. If present- the sign is positive.

    • In advanced case: Chemosis.

Test for eye movement and comment about any palsy.

Look for diplopia. (In thyrotoxicosis diplopia may occur due to paralysis of inferior oblique and superior rectus)

Examination for retrosternal prolongation:-

• • Lower margin of swelling. Whether visible or not- as such or on deglutition.

  • Any dilated vein over the neck & chest wall.

  • Pemberton's sign- Ask the patient to raise both upper limbs above the head and keep it for 2-3 minutes. If retrosternal prolongation is there patient will have congestion and puffiness in the face with respiratory distress. The Pemberton's sign is then positive.

  • Percussion over manubrium sterni- Normally resonant. Dull note suggests retrosternal prolongation of goitre.

Systemic Examination: Describe all systems.